2019 Comprehensive Formulary

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1 2019 Comprehensive Formulary Aetna Medicare (List of Covered Drugs) GRP B2 5 Tier PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on 10/01/2018. For more recent information or other questions, please contact Aetna Medicare Member Services at or for TTY users: 711, 8 a.m. to 6 p.m. local time, Monday through Friday, or visit choose Manage your prescription drugs. Formulary ID Number: Version 7

2 Table of contents Mail-order Pharmacy 3 What is the Aetna Medicare Comprehensive Formulary? 4 Can the Formulary (drug list) change? 4 How do I use the Formulary? 5 What are generic drugs? 5 Are there any restrictions on my coverage? 5 What if my drug is not on the Formulary? 6 How do I request an exception to the Aetna Medicare Formulary? 6 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? 7 For more information 7 Aetna Medicare Formulary 8 Drug tier copay levels 9 Formulary key 10 Drug list 10 Index of Drugs 92 Enhanced drug list 112 2

3 Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Enrollment in our plans depends on contract renewal. You must continue to pay your Medicare Part B premium. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. Members who get Extra Help are not required to fill prescriptions at preferred network pharmacies in order to get Low Income Subsidy (LIS) copays. See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area. Mail-order Pharmacy For mail order, you can get prescription drugs shipped to your home through our preferred mail-order delivery program, which is called Aetna Rx Home Delivery. Typically, mail-order drugs arrive within 7 to 14 days. You can call (TTY: 711), 8 a.m. to 6 p.m. local time, Monday through Friday, if you do not receive your mail-order drugs within this timeframe. Members may have the option to sign up for automated mail-order delivery. ATTENTION: If you speak Spanish or Chinese, language assistance services, free of charge, are available to you. Call the number on your ID card. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que figura en su tarjeta de identificación. 注意 : 如果您使用中文, 您可以免費獲得語言援助服務 請撥打您的會員身分卡上的電話號碼 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Aetna Medicare. When it refers to plan or our plan, it means Aetna. This document includes a list of the drugs (formulary) for our plan which is current as of 10/01/2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year. 3

4 What is the Aetna Medicare Comprehensive Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Aetna Medicare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Prescription Drug Schedule of Cost Sharing. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different costsharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Aetna Medicare Formulary? Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. 4

5 Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier.) Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. The enclosed formulary is current as of 10/01/2018. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 10. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 10. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 92. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per 30 days per prescription for candesartan. This may be in addition to a standard one-month or three-month supply. 5

6 Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 10. You can also get more information about the restrictions applied to specific covered drugs by visiting our Website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Aetna Medicare formulary? on page 6 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Aetna Medicare Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, we will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization 6

7 restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 31-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. If you experience a change in your setting of care (such as being discharged or admitted to a long term care facility), your physician or pharmacy can request a one-time prescription override. This one-time override will provide you with temporary coverage (up to a 30-day supply) for the applicable drug(s). For more information For more detailed information abou our plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit 7

8 Aetna Medicare Formulary The comprehensive formulary that begins on page 10 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 92. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LEVEMIR) and generic drugs are listed in lower-case italics (e.g., candesartan). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. QL PA ST LA MO B/D Quantity Limits Prior Authorization Step Therapy Limited Access Mail-order Delivery Part B vs. D Prior Authorization QL: Quantity Limits. For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per 30 days per prescription for candesartan. PA: Prior Authorization. Our plan requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. ST: Step Therapy. In some cases, our plan requires you to first try certain drugs to treat your medical condition, before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. LA: Limited Access. These prescriptions may be available only at certain pharmacies. For more Information, consult your Pharmacy Directory or call Aetna Member Services at (TTY: 711), 8 a.m. to 6 p.m. local time, Monday through Friday. MO: Mail Order. For certain kinds of drugs, you can use Aetna Rx Home Delivery services. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan s mail-order service are marked as mail-order drugs in our Drug List or MO. For more information, consult your Pharmacy Directory or call Aetna Member Services at (TTY: 711), 8 a.m. to 6 p.m. local time, Monday through Friday. B/D: Part B versus Part D. This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. 8

9 Drug tier copay levels This 2019 comprehensive formulary is a listing of brand-name and generic drugs. Aetna Medicare s 2019 formulary covers most drugs identified by Medicare as Part D drugs, and your copay may differ depending upon the tier at which the drug resides. The copay tiers for covered prescription medications are listed below. Copay amounts and coinsurance percentages for each tier vary by Aetna Medicare plan. Look in the 2019 Prescription Drug Benefits Chart (The Prescription Drug Schedule of Cost Sharing) that was included in your Evidence of Coverage (EOC) packet. Copay tier Tier 1 Tier 2 Tier 3 Tier 4 Type of drug Preferred Generic Drugs Generic Drugs Preferred Brand Drugs Non-Preferred Drugs You may have drug coverage in the Coverage Gap Stage There are four drug payment stages of a Medicare Prescription Drug Plan. How much you pay for a Part D drug depends on which drug payment stage you are in. Your plan may include supplemental coverage for some drugs during the Coverage Gap stage of the plan. Look in the 2019 Prescription Drug Benefits Chart (Prescription Drug Schedule of Cost Sharing) that was included in your EOC packet. The Prescription Drug Benefits Chart will tell you if your plan provides coverage in the gap, and how much you will pay for covered drugs. If you need assistance finding this information, call the number on the back of your ID card. Please Note: Our plan, in some instances, combines higher cost generic drugs on brand tiers. Refer to the drug list to determine the tier of coverage for each drug you take. Tier 5 Specialty Drugs 9

10 Key* Drug name UPPERCASE = Brand-name prescription drugs Lowercase italics = Generic medications Drug name 1, 2, 3, 4, 5 = Copay tier level QL = Quantity Limit PA = Prior Authorization ST = Step Therapy LA = Limited Access MO = Mail-order Delivery B/D = Part B vs. Part D ANALGESICS Analgesics ascomp/codeine 4 QL (180 EA per 30 days) PA MO bupap tabs 300mg; 50mg 4 QL (180 EA per 30 days) PA butalbital/acetaminophen/caffeine/ 4 QL (180 EA per 30 days) PA MO codeine butalbital/acetaminophen/caffeine 4 QL (180 EA per 30 days) PA MO caps butalbital/acetaminophen/caffeine 4 QL (180 EA per 30 days) PA MO tabs 325mg; 50mg; 40mg butalbital/aspirin/caffeine 4 QL (180 EA per 30 days) PA MO butalbital/aspirin/caffeine/codeine 4 QL (180 EA per 30 days) PA MO esgic caps 4 QL (180 EA per 30 days) PA MO phrenilin forte caps 300mg; 50mg; 4 QL (180 EA per 30 days) PA 40mg zebutal caps 325mg; 50mg; 40mg 4 QL (180 EA per 30 days) PA MO Nonsteroidal Anti-inflammatory Drugs CAMBIA 4 PA MO celecoxib caps 400mg 3 QL (30 EA per 30 days) MO celecoxib caps 100mg, 200mg, 50mg 3 QL (60 EA per 30 days) MO diclofenac potassium 2 MO diclofenac sodium dr 2 MO diclofenac sodium er 2 MO diclofenac sodium/misoprostol 4 MO diclofenac sodium transdermal soln 4 QL (450 ML per 30 days) PA MO 1.5% diflunisal tabs 500mg 4 MO DUEXIS 4 MO etodolac er 4 MO etodolac caps, tabs 3 MO fenoprofen calcium caps 400mg 4 MO 10

11 fenoprofen calcium tabs 600mg 4 MO FLECTOR 4 QL (60 EA per 30 days) PA MO flurbiprofen tabs 2 MO ibuprofen susp 2 MO ibuprofen tabs 400mg, 600mg, 1 MO 800mg ibu tabs 600mg, 800mg 1 MO indomethacin er 4 PA MO indomethacin immediate release 4 PA MO caps ketoprofen er cp24 200mg 4 MO ketoprofen caps 50mg, 75mg 4 ketorolac tromethamine inj 15mg/ml, 4 QL (20 ML per 30 days) PA MO 30mg/ml, 60mg/2ml ketorolac tromethamine tabs 10mg 2 QL (20 EA per 30 days) PA MO meclofenamate sodium caps 4 MO meloxicam tabs 1 MO nabumetone tabs 2 MO naproxen dr tabs 375mg, 500mg 2 MO naproxen sodium er tb24 375mg 4 MO naproxen sodium er tb24 500mg 4 MO naproxen sodium tabs 275mg, 550mg 2 MO naproxen tabs 250mg, 375mg, 500mg 1 MO naproxen susp 2 MO oxaprozin 4 MO PENNSAID SOLN 2% 4 QL (224 GM per 28 days) PA MO piroxicam caps 3 MO profeno 4 sulindac tabs 2 MO VIMOVO TBEC 20MG; 500MG 4 MO VIMOVO TBEC 20MG; 375MG 5 MO Opioid Analgesics, Long-acting buprenorphine weekly patch 4 QL (4 EA per 28 days) PA MO fentanyl transdermal patches 4 QL (15 EA per 30 days) PA MO HYSINGLA ER 3 QL (30 EA per 30 days) PA MO methadone hcl tabs 3 QL (180 EA per 30 days) PA MO methadone hcl oral soln 3 QL (3000 ML per 30 days) PA MO methadone hcl oral conc 3 QL (360 ML per 30 days) PA MO * You can find information on what the symbols and abbreviations on this table mean by going to 11

12 methadone hcl inj 5 PA morphine sulfate er cp24 (generic 4 QL (30 EA per 30 days) PA MO Avinza) 120mg, 30mg, 45mg, 60mg, 75mg, 90mg morphine sulfate er cp24 (generic 4 QL (60 EA per 30 days) PA MO Kadian) 100mg, 10mg, 20mg, 30mg, 50mg, 60mg, 80mg morphine sulfate er tbcr (generic MS 3 QL (60 EA per 30 days) PA MO Contin) 100mg, 200mg, 30mg, 60mg morphine sulfate er tbcr (generic MS 3 QL (90 EA per 30 days) PA MO Contin) 15mg NUCYNTA ER TB12 100MG, 200MG, 3 QL (60 EA per 30 days) PA MO 250MG, 50MG NUCYNTA ER TB12 150MG 3 QL (90 EA per 30 days) PA MO tramadol hcl er cp24 100mg, 200mg, 4 QL (30 EA per 30 days) PA MO 300mg tramadol hcl er tb24 100mg, 200mg, 4 QL (30 EA per 30 days) PA MO 300mg Opioid Analgesics, Short-acting acetaminophen/codeine tabs 2 QL (180 EA per 30 days) MO acetaminophen/codeine oral soln 2 QL (4500 ML per 30 days) MO butorphanol tartrate nasal soln 4 QL (5 ML per 30 days) MO butorphanol tartrate inj 1mg/ml 4 butorphanol tartrate inj 2mg/ml 4 MO codeine sulfate tabs 4 QL (180 EA per 30 days) MO endocet tabs 325mg; 10mg, 325mg; 3 QL (180 EA per 30 days) 2.5mg, 325mg; 5mg, 325mg; 7.5mg fentanyl citrate oral transmucosal 5 QL (120 EA per 30 days) PA MO lozenge FENTORA TABS 100MCG, 200MCG, 5 QL (120 EA per 30 days) PA MO 400MCG, 600MCG, 800MCG hydrocodone/acetaminophen oral 3 QL (5550 ML per 30 days) MO soln 325mg/15ml; 7.5mg/15ml hydrocodone/acetaminophen 3 QL (180 EA per 30 days) MO tabs 10mg/300mg, 5mg/300mg,7.5mg/300mg, 2.5/325mg hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg 3 QL (180 EA per 30 days) MO 12

13 hydrocodone/ibuprofen tabs 10mg; 200mg, 5mg; 200mg, 7.5mg; 200mg 3 QL (150 EA per 30 days) MO hydromorphone hcl immediate 3 QL (180 EA per 30 days) MO release tabs hydromorphone hcl oral soln 4 QL (2400 ML per 30 days) MO hydromorphone hcl inj 10mg/ml, 4 B/D 50mg/5ml hydromorphone hcl inj 1mg/ml, 2mg/ 4 B/D MO ml, 4mg/ml ibudone tabs 5mg; 200mg 4 QL (150 EA per 30 days) lorcet 4 QL (180 EA per 30 days) lorcet hd 4 QL (180 EA per 30 days) lorcet plus tabs 325mg; 7.5mg 4 QL (180 EA per 30 days) meperidine hcl tabs 4 QL (120 EA per 30 days) PA MO meperidine hcl oral soln 4 QL (3600 ML per 30 days) PA MO meperidine hcl inj 10mg/ml, 25mg/ml 4 PA meperidine hcl inj 100mg/ml, 50mg/ ml 4 PA MO morphine sulfate inj 0.5mg/ml, 10mg/ 4 B/D ml, 150mg/30ml, 1mg/ml pf, 25mg/ ml, 2mg/ml, 4mg/ml, 50mg/ml, 5mg/ ml, 8mg/ml morphine sulfate inj 1mg/ml 4 B/D MO morphine sulfate oral soln 10mg/5ml 3 QL (1800 ML per 30 days) MO morphine sulfate oral soln 20mg/5ml 3 QL (900 ML per 30 days) MO morphine sulfate oral soln 4 QL (180 ML per 30 days) MO 100mg/5ml morphine sulfate tabs 30mg 3 QL (180 EA per 30 days) MO morphine sulfate tabs 15mg 3 QL (60 EA per 30 days) MO nalbuphine hcl inj 10mg/ml, 20mg/ml 3 MO oxycodone hcl caps 3 QL (180 EA per 30 days) MO oxycodone hcl oral soln 3 QL (5400 ML per 30 days) MO oxycodone hcl oral conc 4 QL (180 ML per 30 days) MO oxycodone hcl tabs 30mg 3 QL (120 EA per 30 days) MO oxycodone hcl tabs 10mg, 15mg, 3 QL (180 EA per 30 days) MO 20mg, 5mg oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg 3 QL (180 EA per 30 days) MO 13

14 14 oxycodone/aspirin tabs 325mg; 4 QL (180 EA per 30 days) MO 4.835mg oxycodone/ibuprofen 3 QL (120 EA per 30 days) MO oxymorphone hcl immediate release 4 QL (180 EA per 30 days) MO tabs pentazocine/naloxone hcl 4 QL (360 EA per 30 days) PA MO tramadol hcl immediate release tabs 2 QL (240 EA per 30 days) MO tramadol hydrochloride/ 4 QL (240 EA per 30 days) MO acetaminophen vicodin es tabs 300mg; 7.5mg 4 QL (180 EA per 30 days) vicodin hp tabs 300mg; 10mg 4 QL (180 EA per 30 days) vicodin tabs 300mg; 5mg 4 QL (180 EA per 30 days) ANESTHETICS Local Anesthetics lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4 4% lidocaine hcl topical soln 4% 4 MO lidocaine viscous oral topical soln 4 MO lidocaine/prilocaine crea 4 QL (30 GM per 30 days) PA MO lidocaine ptch 3 QL (90 EA per 30 days) PA MO lidocaine oint 4 QL (35.44 GM per 30 days) PA MO ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving acamprosate calcium dr 4 MO disulfiram tabs 4 MO naltrexone hcl tabs 3 MO VIVITROL INJ 5 Opioid Dependence Treatments buprenorphine hcl/naloxone hcl subl 2 QL (90 EA per 30 days) MO buprenorphine hcl subl 2 QL (90 EA per 30 days) PA MO SUBOXONE FILM 12MG; 3MG 4 QL (60 EA per 30 days) MO SUBOXONE FILM 2MG; 0.5MG, 4 QL (90 EA per 30 days) MO 4MG; 1MG, 8MG; 2MG Opioid Reversal Agents naloxone hcl inj 0.4mg/ml, 2mg/2ml 3 naloxone hcl inj 0.4mg/ml, 4mg/10ml 3 MO NARCAN NASAL SPRAY 3 MO Smoking Cessation Agents bupropion hcl sr tb12 150mg 3 QL (60 EA per 30 days) MO

15 ANTIBACTERIALS CHANTIX CONTINUING MONTH PAK 4 PA MO CHANTIX STARTING MONTH PAK 4 PA MO CHANTIX TABS 0.5MG, 1MG 4 PA MO NICOTROL INHALER 4 MO NICOTROL NASAL SPRAY 4 MO Aminoglycosides amikacin sulfate inj 1gm/4ml, 4 MO 500mg/2ml gentamicin sulfate inj 10mg/ml 4 MO gentamicin sulfate/0.9% sodium 4 chloride inj 1.2mg/ml, 1.6mg/ml, 1mg/ml, 2mg/ml gentamicin sulfate inj 40mg/ml 4 MO isotonic gentamicin inj 0.8mg/ml; 4 MO 0.9% neomycin sulfate tabs 2 MO paromomycin sulfate caps 4 MO streptomycin sulfate inj 1gm 4 MO tobramycin sulfate inj 1.2gm, 10mg/ 4 ml, 40mg/ml tobramycin sulfate inj 1.2gm/30ml, 4 MO 80mg/2ml Antibacterials, Other baciim inj 4 bacitracin inj 50000unit 4 MO chloramphenicol sodium succinate inj 4 clindamycin hcl caps 2 MO clindamycin palmitate hcl oral soln 4 MO 75mg/5ml clindamycin phosphate in d5w inj 4 clindamycin phosphate inj 4 900mg/6ml clindamycin phosphate vaginal crea 4 MO 2% clindamycin phosphate inj 150mg/ 4 ml, 300mg/2ml, 600mg/4ml, 9000mg/60ml clindamycin phosphate inj 600mg/4ml 4 MO 15

16 16 CLINDAMYCIN/SODIUM CHLORIDE IV SOLN colistimethate sodium inj 4 PA MO daptomycin inj 500mg 5 4 ISOPROPYL ALCOHOL WIPES 3 lansoprazole/amoxicillin/ 4 QL (224 EA per 365 days) MO clarithromycin linezolid inj 5 PA linezolid oral susp 5 QL (1800 ML per 28 days) PA MO linezolid tabs 5 QL (56 EA per 28 days) PA MO MACROBID 4 MO methenamine hippurate 4 MO methenamine mandelate tabs 0.5gm, 4 MO 1gm metronidazole in nacl 0.79% 4 metronidazole vaginal gel 4 MO metronidazole caps 375mg 3 MO metronidazole inj 5mg/ml 4 metronidazole tabs 250mg, 500mg 3 MO MONUROL 4 MO nitrofurantoin macrocrystals 3 MO nitrofurantoin monohydrate 3 MO nitrofurantoin susp 4 MO SIVEXTRO INJ 5 SIVEXTRO TABS 5 MO SYNERCID INJ 500MG 5 tigecycline inj 5 tinidazole 4 MO trimethoprim tabs 1 MO VANCOMYCIN HCL INJ 4 0.9%; 500MG/100ML, 0.9%; 750MG/150ML vancomycin hcl caps 125mg 4 QL (120 EA per 30 days) MO vancomycin hcl caps 250mg 5 MO VANCOMYCIN HCL IN SODIUM 4 CHLORIDE INJ 0.9%; 1GM/200ML vancomycin hcl inj 1000mg, 100gm, 4 10gm, 5000mg, 750mg vancomycin hcl inj 500mg 4 MO VANDAZOLE VAGINAL GEL 4 MO

17 XIFAXAN TABS 550MG 5 PA MO Beta-lactam, Cephalosporins cefaclor er tb12 500mg 4 MO cefaclor caps 3 MO cefaclor oral susp 125mg/5ml, 250mg/5ml, 375mg/5ml 2 MO cefadroxil 2 MO CEFAZOLIN/ DEXTROSE INJ 1GM/50ML cefazolin sodium inj 100gm, 1gm, 20gm, 300gm cefazolin sodium inj 10gm, 1gm, 500mg CEFAZOLIN/DEXTROSE INJ 2GM/100ML MO cefdinir caps 2 MO cefdinir oral susp 3 MO cefepime inj 1gm, 2gm 4 MO cefixime oral susp 4 MO cefotaxime sodium inj 10gm, 2gm, 500mg cefotaxime sodium inj 1gm 4 MO cefotetan inj 4 cefoxitin sodium inj 10gm, 1gm, 2gm 4 cefpodoxime proxetil 4 MO cefprozil 3 MO CEFTAZIDIME/DEXTROSE IV INJ 4 ceftazidime inj 6gm 4 ceftazidime inj 1gm, 2gm 4 MO ceftriaxone sodium inj 100gm, 1gm 4 ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg ceftriaxone/dextrose iv soln MO cefuroxime axetil tabs 3 MO cefuroxime sodium inj 1.5gm, 7.5gm 4 cefuroxime sodium inj 750mg 4 MO cephalexin 2 MO SUPRAX CAPS 3 MO SUPRAX CHEW 100MG 4 SUPRAX CHEW 200MG 4 MO 17

18 18 SUPRAX ORAL SUSP 500MG/5ML 3 tazicef inj 1gm, 2gm, 6gm 4 TEFLARO 5 Beta-lactam, Other AZACTAM IN ISO-OSMOTIC 4 DEXTROSE INJ 1GM/50ML, 2GM/50ML AZACTAM INJ 1GM, 2GM 4 aztreonam inj 1gm 4 MO aztreonam inj 2gm 5 MO imipenem/cilastatin 4 MO INVANZ IV 1GM 4 INVANZ INJ 1GM 4 MO meropenem vial 4 MO Beta-lactam, Penicillins amoxicillin/clavulanate potassium 2 MO amoxicillin/clavulanate potassium er 4 MO amoxicillin chew 125mg, 250mg 1 MO amoxicillin caps, oral susp, tabs 1 MO ampicillin sodium inj 10gm, 125mg, 4 1gm, 250mg, 2gm ampicillin sodium inj 1gm, 2gm, 4 MO 500mg ampicillin-sulbactam inj 4 ampicillin caps 500mg 1 MO AUGMENTIN ES-600 ORAL SUSP 4 MO AUGMENTIN XR 4 AUGMENTIN ORAL SUSP 4 MO 125MG/5ML AUGMENTIN ORAL SUSP 5 MO 250MG/5ML AUGMENTIN TABS 500MG, 875MG 4 MO BICILLIN L-A INJ UNIT/2ML, 4 MO UNIT/4ML, UNIT/ML dicloxacillin sodium 2 MO nafcillin sodium inj 1gm, 2gm 4 nafcillin sodium inj 2gm 4 MO nafcillin sodium inj 10gm 5 oxacillin sodium inj 10gm, 1gm 4 oxacillin sodium inj 2gm 4 MO

19 PENICILLIN G POTASSIUM IN ISO- 4 OSMOTIC DEXTROSE INJ penicillin g potassium inj 4 MO unit, unit penicillin g procaine inj 4 MO penicillin g sodium inj 4 penicillin v potassium 1 MO piperacillin sodium/ tazobactam 4 sodium inj 36gm; 4.5gm piperacillin sodium/tazobactam 4 sodium inj 3gm; 0.375gm piperacillin/tazobactam inj 12gm; 4 1.5gm, 2gm; 0.25gm, 4gm; 0.5gm Macrolides AZITHROMYCIN 1 GM PACK FOR 3 MO ORAL SUSPENSION azithromycin oral susp, tabs 1 MO azithromycin inj 500mg 4 MO clarithromycin er 4 MO clarithromycin oral susp, tabs 3 MO DIFICID 5 MO E.E.S. 400 TABS 4 MO ERY-TAB 4 MO ERYTHROCIN LACTOBIONATE INJ 4 500MG ERYTHROCIN STEARATE TABS 4 MO 250MG erythromycin base tabs 3 MO erythromycin ethylsuccinate tabs 3 MO erythromycin stearate tabs 250mg 3 MO erythromycin caps dr 250mg 3 MO Quinolones ciprofloxacin er 3 MO ciprofloxacin hcl tabs 100mg, 250mg, 1 MO 750mg ciprofloxacin hydrochloride tabs 1 MO ciprofloxacin iv in d5w 200mg/100ml 4 iv soln ciprofloxacin iv in d5w 400mg/200ml iv soln 4 MO 19

20 CIPROFLOXACIN OTIC SOLN 3 MO ciprofloxacin inj 4 ciprofloxacin oral susp 250mg/5ml 3 ciprofloxacin oral susp 500mg/5ml 3 MO levofloxacin in d5w iv soln 4 levofloxacin inj 25mg/ml 4 levofloxacin oral soln 25mg/ml 3 MO levofloxacin tabs 250mg, 500mg, 750mg moxifloxacin hcl/sodium chloride 400mg/250ml iv soln MOXIFLOXACIN HCL INJ 4 2 MO moxifloxacin hcl tabs 4 MO moxifloxacin hcl ophthalmic soln 3 MO ofloxacin tabs 300mg, 400mg 2 MO Sulfonamides sulfadiazine tabs 4 MO sulfamethoxazole/trimethoprim ds 1 MO sulfamethoxazole/trimethoprim tabs 1 MO sulfamethoxazole/trimethoprim inj, 4 MO susp Tetracyclines doxy 100 inj 4 MO doxycycline hyclate dr 4 MO doxycycline hyclate caps 3 MO doxycycline hyclate inj 4 MO doxycycline hyclate tabs 100mg, 3 MO 150mg, 20mg, 75mg doxycycline monohydrate tabs 2 MO doxycycline monohydrate caps 4 MO doxycycline oral susp 25mg/5ml 3 MO minocycline hcl er 65mg, 115mg 4 ST MO minocycline hcl caps 2 MO minocycline hcl tabs 4 ST MO morgidox 1x100mg caps 4 morgidox 1x50mg caps 4 morgidox 2x100mg caps 4 okebo 4 soloxide

21 tetracycline hydrochloride 4 MO ANTICONVULSANTS Anticonvulsants, Other APTIOM TABS 200MG 5 QL (180 EA per 30 days) MO APTIOM TABS 600MG, 800MG 5 QL (60 EA per 30 days) MO APTIOM TABS 400MG 5 QL (90 EA per 30 days) MO BRIVIACT INJ 4 PA BRIVIACT ORAL SOLN, TABS 5 PA MO FYCOMPA SUSP 5 QL (720 ML per 30 days) PA MO FYCOMPA TABS 2MG 4 QL (60 EA per 30 days) PA MO FYCOMPA TABS 10MG, 12MG, 8MG 5 QL (30 EA per 30 days) PA MO FYCOMPA TABS 4MG, 6MG 5 QL (60 EA per 30 days) PA MO levetiracetam er 4 MO levetiracetam oral soln, tabs 2 MO levetiracetam inj 5mg/ml, 10mg/ml, 4 15mg/ml levetiracetam inj 500mg/5ml 4 MO roweepra 2 roweepra xr 4 SPRITAM 4 MO Calcium Channel Modifying Agents CELONTIN CAPS 300MG 4 MO ethosuximide 4 MO LYRICA ORAL SOLN 3 QL (946 ML per 30 days) MO LYRICA CAPS 100MG, 150MG, 3 QL (120 EA per 30 days) MO 25MG, 50MG, 75MG LYRICA CAPS 225MG, 300MG 3 QL (60 EA per 30 days) MO LYRICA CAPS 200MG 3 QL (90 EA per 30 days) MO zonisamide 2 MO Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tbdp 1mg 3 QL (120 EA per 30 days) MO clonazepam odt tbdp 2mg 3 QL (300 EA per 30 days) MO clonazepam odt tbdp 0.125mg, 3 QL (90 EA per 30 days) MO 0.25mg, 0.5mg clonazepam tabs 1mg 1 QL (120 EA per 30 days) MO clonazepam tabs 2mg 1 QL (300 EA per 30 days) MO clonazepam tabs 0.5mg 1 QL (90 EA per 30 days) MO DIASTAT ACUDIAL 4 MO DIASTAT PEDIATRIC GEL 2.5MG 4 MO 21

22 diazepam gel 10mg, 2.5mg, 20mg 4 MO divalproex sodium dr 3 MO divalproex sodium er 4 MO divalproex sodium sprinkle caps 3 MO gabapentin soln 3 QL (2160 ML per 30 days) MO gabapentin caps 3 QL (90 EA per 30 days) MO gabapentin tabs 600mg 3 QL (180 EA per 30 days) MO gabapentin tabs 800mg 3 QL (90 EA per 30 days) MO GABITRIL TABS 12MG, 16MG 4 MO GABITRIL TABS 2MG, 4MG 5 MO ONFI SUSP 5 PA MO ONFI TABS 10MG, 20MG 5 PA MO phenobarbital elix 4 QL (1500 ML per 30 days) PA MO phenobarbital tabs 100mg, 15mg, 16.2mg, 30mg, 32.4mg, 60mg, 64.8mg, 97.2mg primidone tabs 2 MO 4 QL (120 EA per 30 days) PA MO SABRIL TABS 5 QL (180 EA per 30 days) PA LA tiagabine hydrochloride 4 MO valproate sodium inj 100mg/ml 4 valproic acid caps, soln 2 MO vigabatrin 500mg pack oral susp 5 QL (180 EA per 30 days) PA Glutamate Reducing Agents felbamate 4 MO lamotrigine er 4 MO lamotrigine odt 4 MO lamotrigine starter kit/blue 4 MO lamotrigine starter kit/green 4 MO lamotrigine starter kit/orange 4 MO lamotrigine chew, tabs 2 MO topiramate er 4 MO topiramate sprinkle caps, tabs 2 MO Sodium Channel Agents BANZEL 5 PA MO carbamazepine er 4 MO carbamazepine chew, susp, tabs 2 MO DILANTIN INFATABS CHEW TABS 3 MO DILANTIN-125 ORAL SUSP 4 MO DILANTIN CAPS 3 MO 22

23 epitol 4 fosphenytoin sodium inj 100mg 4 pe/2ml fosphenytoin sodium inj 500mg 4 MO pe/10ml oxcarbazepine tabs 3 MO oxcarbazepine susp 4 MO PEGANONE TABS 250MG 4 MO PHENYTEK 3 MO phenytoin sodium er caps 3 MO phenytoin sodium inj 4 phenytoin chew, susp 3 MO VIMPAT INJ 5 VIMPAT ORAL SOLN 5 QL (1200 ML per 30 days) MO VIMPAT TABS 50MG 4 QL (120 EA per 30 days) MO VIMPAT TABS 100MG, 150MG, 5 QL (60 EA per 30 days) MO 200MG ANTIDEMENTIA AGENTS Antidementia Agents, Other ergoloid mesylates tabs 3 PA MO NAMZARIC 4 MO Cholinesterase Inhibitors donepezil hcl odt 2 QL (30 EA per 30 days) MO donepezil hcl tabs 23mg, 5mg 2 QL (30 EA per 30 days) MO donepezil hcl tabs 10mg 2 QL (60 EA per 30 days) MO galantamine hydrobromide er caps 4 QL (30 EA per 30 days) MO galantamine hydrobromide soln 4 QL (200 ML per 30 days) MO galantamine hydrobromide tabs 4 QL (60 EA per 30 days) MO rivastigmine patch 4 QL (30 EA per 30 days) MO rivastigmine tartrate 4 QL (60 EA per 30 days) MO N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl 3 QL (60 EA per 30 days) PA MO memantine hcl titration pak 3 QL (98 EA per 365 days) PA MO memantine hydrochloride er 4 PA MO memantine hydrochloride soln 3 QL (360 ML per 30 days) PA MO ANTIDEPRESSANTS Antidepressants, Other bupropion hcl sr tb12 100mg, 150mg, 200mg 3 QL (60 EA per 30 days) MO 23

24 bupropion hcl xl 3 QL (30 EA per 30 days) MO bupropion hcl tabs 100mg 3 QL (180 EA per 30 days) MO bupropion hydrochloride tabs 75mg 3 QL (180 EA per 30 days) MO mirtazapine odt 3 QL (30 EA per 30 days) MO mirtazapine tabs 2 QL (30 EA per 30 days) MO TRINTELLIX TABS 5MG 4 QL (120 EA per 30 days) MO TRINTELLIX TABS 20MG 4 QL (30 EA per 30 days) MO TRINTELLIX TABS 10MG 4 QL (60 EA per 30 days) MO Monoamine Oxidase Inhibitors EMSAM PATCH 5 QL (30 EA per 30 days) PA MO MARPLAN 4 QL (180 EA per 30 days) MO phenelzine sulfate 3 MO tranylcypromine sulfate 4 MO SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide soln 3 QL (600 ML per 30 days) MO citalopram hydrobromide tabs 10mg 1 QL (120 EA per 30 days) MO citalopram hydrobromide tabs 40mg 1 QL (30 EA per 30 days) MO citalopram hydrobromide tabs 20mg 1 QL (60 EA per 30 days) MO DESVENLAFAXINE ER TB24 (BRANDED GENERIC KHEDEZLA) 100MG, 50MG desvenlafaxine er tb24 (generic Pristiq) 100mg, 25mg, 50mg 3 QL (30 EA per 30 days) MO 3 QL (30 EA per 30 days) MO duloxetine hcl dr caps 20mg, 40mg 3 QL (60 EA per 30 days) MO duloxetine hcl dr caps 60mg 3 QL (60 EA per 30 days) MO duloxetine hcl dr caps 30mg 3 QL (90 EA per 30 days) MO escitalopram oxalate soln 3 QL (600 ML per 30 days) MO escitalopram oxalate tabs 20mg 3 QL (30 EA per 30 days) MO escitalopram oxalate tabs 10mg, 5mg 3 FETZIMA TITRATION PACK 4 PA MO QL (45 EA per 30 days) MO FETZIMA ER CAP 20MG 4 QL (180 EA per 30 days) PA MO FETZIMA ER CAP 120MG, 80MG 4 QL (30 EA per 30 days) PA MO FETZIMA ER CAP 40MG 4 QL (90 EA per 30 days) PA MO fluoxetine dr caps 90mg 4 QL (4 EA per 28 days) MO fluoxetine hcl caps 20mg 2 QL (120 EA per 30 days) MO fluoxetine hcl caps 10mg 2 QL (30 EA per 30 days) MO fluoxetine hcl caps 40mg 2 QL (60 EA per 30 days) MO fluoxetine hcl soln 2 MO 24

25 FLUOXETINE HYDROCHLORIDE 3 MO TABS 60MG fluoxetine hcl tabs (generic Prozac) 2 MO 10mg, 20mg fluvoxamine maleate 2 MO fluvoxamine maleate er 4 QL (60 EA per 30 days) MO maprotiline hcl 4 MO nefazodone hcl tabs 100mg, 150mg, 4 MO 250mg, 50mg nefazodone hydrochloride tabs 4 MO 200mg olanzapine/fluoxetine 4 QL (30 EA per 30 days) MO paroxetine hcl er tb mg 4 QL (60 EA per 30 days) MO paroxetine hcl er tb mg, 25mg 4 QL (90 EA per 30 days) MO paroxetine hcl tabs 10mg, 20mg 2 QL (30 EA per 30 days) MO paroxetine hcl tabs 30mg, 40mg 2 QL (60 EA per 30 days) MO PAXIL SUSP 4 QL (900 ML per 30 days) MO sertraline hcl conc 3 QL (300 ML per 30 days) MO sertraline hcl tabs 25mg 1 QL (30 EA per 30 days) MO sertraline hcl tabs 100mg, 50mg 1 QL (60 EA per 30 days) MO trazodone hydrochloride 1 MO venlafaxine hcl 3 MO venlafaxine hcl er cp mg, 75mg 3 QL (30 EA per 30 days) MO venlafaxine hcl er cp24 150mg 3 QL (60 EA per 30 days) MO venlafaxine hcl er tb24 225mg, 3 QL (30 EA per 30 days) MO 37.5mg, 75mg venlafaxine hcl er tb24 150mg 3 QL (60 EA per 30 days) MO venlafaxine hydrochloride er tb24 3 QL (30 EA per 30 days) MO 37.5mg, 75mg VIIBRYD STARTER PACK 4 MO VIIBRYD TABS 4 QL (30 EA per 30 days) MO Tricyclics amitriptyline hcl tabs 3 PA MO amoxapine 3 MO chlordiazepoxide/amitriptyline 4 PA MO clomipramine hcl caps 4 PA MO desipramine hcl tabs 4 MO doxepin hcl caps, conc 3 PA MO imipramine hcl tabs 25mg, 50mg 2 PA MO imipramine hydrochloride tabs 10mg 2 PA MO 25

26 ANTIEMETICS imipramine pamoate caps 4 PA MO nortriptyline hcl caps, soln 2 MO perphenazine/amitriptyline 4 PA MO protriptyline hcl 4 MO trimipramine maleate caps 4 PA MO Antiemetics, Other dimenhydrinate inj 4 meclizine hcl tabs 2 MO phenadoz supp 25mg 4 PA phenadoz supp 12.5mg 4 PA MO phenergan supp 4 PA promethazine hcl supp 12.5mg, 4 PA MO 25mg, 50mg promethegan supp 12.5mg, 25mg 4 PA promethegan supp 50mg 4 PA MO scopolamine transdermal patch 4 QL (10 EA per 30 days) PA MO TRANSDERM-SCOP 4 QL (10 EA per 30 days) PA MO trimethobenzamide hcl caps 300mg 4 PA MO Emetogenic Therapy Adjuncts aprepitant 4 B/D MO dronabinol 4 QL (60 EA per 30 days) PA MO EMEND ORAL SUSP 4 B/D granisetron hcl tabs 3 QL (60 EA per 30 days) B/D MO ondansetron hcl oral soln 3 QL (900 ML per 30 days) B/D MO ondansetron hcl inj 40mg/20ml, 4 MO 4mg/2ml ondansetron hcl tabs 24mg 2 B/D ondansetron hcl tabs 4mg, 8mg 2 B/D MO ondansetron odt 2 B/D MO SANCUSO 5 QL (4 EA per 28 days) MO ANTIFUNGALS Antifungals ABELCET INJ 5 B/D AMBISOME INJ 5 B/D amphotericin b inj 4 B/D MO caspofungin acetate inj 50mg 5 caspofungin acetate inj 70mg 5 MO ciclodan topical soln 3 26

27 ciclopirox nail lacquer 3 MO ciclopirox olamine crea 3 QL (90 GM per 30 days) MO ciclopirox susp 3 MO ciclopirox gel 3 QL (100 GM per 30 days) MO ciclopirox sham 3 QL (120 ML per 30 days) MO clotrimazole/betamethasone 4 QL (30 ML per 30 days) MO dipropionate lotn clotrimazole/betamethasone 4 QL (45 GM per 30 days) MO dipropionate crea clotrimazole lozg 3 MO clotrimazole topical soln 3 QL (30 ML per 30 days) MO clotrimazole crea 3 QL (45 GM per 30 days) MO econazole nitrate crea 4 QL (85 GM per 30 days) MO ERTACZO CREA 5 QL (60 GM per 30 days) MO fluconazole in d5w iv inj 4 200mg/100ml, 400mg/200ml fluconazole in sodium chloride 0.9% 4 iv soln 200mg/100ml, 400mg/200ml fluconazole tabs 2 MO fluconazole oral susp 3 MO flucytosine caps 5 MO griseofulvin microsize oral susp, tabs 4 MO griseofulvin ultramicrosize tabs 4 MO 125mg, 250mg itraconazole caps 4 PA MO ketoconazole tabs 2 MO ketoconazole sham 2 QL (120 ML per 30 days) MO ketoconazole crea 3 QL (60 GM per 30 days) MO ketoconazole foam 4 QL (100 GM per 30 days) MO miconazole 3 supp 4 MO MYCAMINE INJ 100MG 5 MYCAMINE INJ 50MG 5 MO naftifine hcl 1% cream 4 QL (90 GM per 30 days) MO naftifine hcl 2% cream 4 QL (60 GM per 30 days) MO NOXAFIL SUSP 5 QL (630 ML per 30 days) MO NOXAFIL TBEC 5 QL (93 EA per 30 days) MO nyamyc 3 nystatin/triamcinolone 4 QL (60 GM per 30 days) MO nystatin crea 2 QL (30 GM per 30 days) MO 27

28 nystatin powd 3 MO nystatin susp, tabs 4 MO nystatin oint 4 QL (30 GM per 30 days) MO nystop 3 MO oxiconazole nitrate 4 QL (90 GM per 30 days) MO terbinafine hcl tabs 2 MO terconazole crea 3 MO terconazole supp 4 MO voriconazole inj 4 voriconazole oral susp, tabs 4 MO ANTIGOUT AGENTS Antigout Agents allopurinol tabs 1 MO colchicine caps 3 QL (60 EA per 30 days) MO colchicine tabs 0.6mg 3 QL (120 EA per 30 days) MO COLCRYS 3 QL (120 EA per 30 days) MO MITIGARE 3 QL (60 EA per 30 days) MO probenecid/colchicine 3 MO probenecid tabs 3 MO ULORIC 3 ST MO ANTIMIGRAINE AGENTS Ergot Alkaloids dihydroergotamine mesylate inj 4 PA MO dihydroergotamine mesylate nasal 4 QL (8 ML per 28 days) PA MO soln ergotamine tartrate/caffeine 3 MO Serotonin (5-HT) 1b/1d Receptor Agonists almotriptan malate 4 QL (8 EA per 30 days) MO eletriptan hydrobromide 3 QL (12 EA per 30 days) MO frovatriptan succinate 4 QL (12 EA per 30 days) MO naratriptan hcl 3 QL (9 EA per 30 days) MO rizatriptan benzoate odt 3 QL (12 EA per 30 days) MO rizatriptan benzoate tabs 3 QL (12 EA per 30 days) MO sumatriptan succinate refill inj 4 QL (4 ML per 30 days) 6mg/0.5ml sumatriptan succinate refill inj 4 QL (4 ML per 30 days) MO 4mg/0.5ml sumatriptan succinate tabs 2 QL (9 EA per 30 days) MO sumatriptan succinate inj 4 QL (4 ML per 30 days) MO 28

29 sumatriptan/naproxen sodium 4 QL (9 EA per 30 days) MO sumatriptan nasal spray 2 QL (12 EA per 30 days) MO zolmitriptan odt 4 QL (6 EA per 30 days) MO zolmitriptan tabs 4 QL (6 EA per 30 days) MO ANTIMYASTHENIC AGENTS Parasympathomimetics GUANIDINE HCL 4 pyridostigmine bromide er 3 MO pyridostigmine bromide tabs 3 MO ANTIMYCOBACTERIALS Antimycobacterials, Other dapsone tabs 100mg, 25mg 3 MO rifabutin 4 MO Antituberculars cycloserine 5 MO ethambutol hcl tabs 4 MO isoniazid tabs 1 MO isoniazid syrp 2 MO isoniazid inj 4 PASER 4 MO PRIFTIN 4 MO pyrazinamide tabs 4 MO rifampin caps 3 MO rifampin inj 4 RIFATER 4 MO SIRTURO 5 PA LA TRECATOR 4 MO ANTINEOPLASTICS Alkylating Agents BENDEKA INJ 5 busulfan inj 5 CYCLOPHOSPHAMIDE CAPS 4 B/D MO cyclophosphamide inj 4 GLEOSTINE CAPS 10MG, 5MG 4 GLEOSTINE CAPS 100MG, 40MG 4 MO HEXALEN 5 MO KISQALI FEMARA 200MG-2.5MG CO-PACK 5 PA 29

30 KISQALI FEMARA 400MG-2.5MG CO-PACK KISQALI FEMARA 600MG-2.5MG CO-PACK 5 PA 5 PA LEUKERAN 5 MO MATULANE 5 LA melphalan hcl tablet 5 melphalan inj 4 B/D MO MUSTARGEN 5 thiotepa inj 15mg 5 VALCHLOR 5 QL (60 GM per 30 days) PA MO Antiandrogens bicalutamide 3 MO ERLEADA 5 PA LA flutamide 4 MO nilutamide 5 MO XTANDI 5 PA LA ZYTIGA 5 PA LA Antiangiogenic Agents POMALYST 5 PA LA REVLIMID 5 QL (28 EA per 28 days) PA LA THALOMID CAPS 100MG, 50MG 5 QL (30 EA per 30 days) PA THALOMID CAPS 150MG, 200MG 5 QL (60 EA per 30 days) PA Antiestrogens/Modifiers EMCYT 4 MO FARESTON 5 MO SOLTAMOX 5 MO tamoxifen citrate tabs 2 MO Antimetabolites clofarabine 5 DROXIA 3 MO fluorouracil inj 1gm/20ml 3 B/D hydroxyurea caps 2 MO mercaptopurine tabs 4 MO PURIXAN 5 TABLOID 4 MO Antineoplastics, Other ABRAXANE 5 adrucil 3 B/D 30

31 ALIMTA 5 AVASTIN 5 PA LA bleomycin sulfate 4 B/D BORTEZOMIB 5 PA carboplatin 3 cisplatin 3 cladribine 4 B/D cytarabine aqueous inj 4 B/D dacarbazine 4 dactinomycin 5 daunorubicin hcl inj 5mg/ml 4 decitabine 4 dexrazoxane 4 DOCETAXEL INJ 160MG/16ML, 5 20MG/2ML, 80MG/8ML docetaxel inj 20mg/ml 4 docetaxel inj 160mg/8ml, 5 200mg/10ml, 80mg/4ml doxorubicin hcl liposome 4 doxorubicin hcl inj 10mg, 2mg/ml, 4 B/D 50mg epirubicin hcl inj 200mg/100ml, 4 50mg/25ml FASLODEX 5 fludarabine phosphate 4 fluorouracil inj 2.5gm/50ml, 3 B/D 5gm/100ml gemcitabine 4 gemcitabine hcl 4 HERCEPTIN INJ 440MG 5 PA idarubicin hcl 4 IFEX 4 ifosfamide 4 INTRON A INJ 10MU/ML, 10MU, 5 18MU irinotecan 4 KADCYLA 5 KISQALI 5 PA leucovorin calcium tabs 3 MO 31

32 leucovorin calcium inj 100mg, 200mg, 4 350mg, 500mg, 50mg levoleucovorin calcium inj 5 B/D 175mg/17.5ml (10mg/ml) LEVOLEUCOVORIN INJ 175MG 5 B/D levoleucovorin inj 175mg/17.5ml, 5 B/D 250mg/25ml, 50mg LONSURF 5 PA LYNPARZA TABS 100MG, 150MG 5 PA LA MO mitomycin inj 20mg, 5mg 4 mitomycin inj 40mg 5 mitoxantrone hcl inj 2mg/ml 3 mutamycin inj 20mg, 5mg 4 mutamycin inj 40mg 5 NERLYNX 5 PA LA NINLARO 5 PA NIPENT INJ 5 oxaliplatin 4 paclitaxel inj 100mg/16.7ml, 4 150mg/25ml, 300mg/50ml, 30mg/5ml romidepsin 5 RUBRACA 5 PA LA RYDAPT 5 PA SYNRIBO 5 PA TAXOTERE INJ 80MG/4ML 5 TRISENOX INJ 12MG/6ML 5 VELCADE 5 PA VERZENIO 5 PA LA vinblastine sulfate inj 1mg/ml 4 B/D vincasar pfs 4 B/D vincristine sulfate 4 B/D vinorelbine tartrate 4 YERVOY 5 PA ZEJULA 5 PA LA MO ZOLINZA 5 PA Aromatase Inhibitors, 3rd Generation anastrozole tabs 2 MO exemestane 4 MO letrozole 2 MO 32

33 Enzyme Inhibitors etoposide inj 100mg/5ml, 1gm/50ml, 500mg/25ml toposar inj 100mg/5ml, 1gm/50ml, 500mg/25ml TOPOTECAN HCL INJ 4MG/4ML 5 topotecan hcl inj 4mg 5 Molecular Target Inhibitors 3 3 AFINITOR 5 QL (30 EA per 30 days) PA AFINITOR DISPERZ TBSO 2MG 5 QL (150 EA per 30 days) PA AFINITOR DISPERZ TBSO 5MG 5 QL (60 EA per 30 days) PA AFINITOR DISPERZ TBSO 3MG 5 QL (90 EA per 30 days) PA ALECENSA 5 PA LA ALUNBRIG 5 PA LA BELEODAQ 5 PA BOSULIF 5 PA CABOMETYX 5 QL (30 EA per 30 days) PA LA CALQUENCE 5 PA LA MO CAPRELSA 5 PA LA MO COMETRIQ 5 PA LA MO COTELLIC 5 PA LA ERIVEDGE 5 PA LA FARYDAK 5 PA LA GILOTRIF 5 PA LA MO IBRANCE 5 PA LA ICLUSIG 5 PA LA MO IDHIFA 5 PA LA imatinib mesylate tabs 400mg 5 QL (60 EA per 30 days) PA imatinib mesylate tabs 100mg 5 QL (90 EA per 30 days) PA IMBRUVICA TABS 5 PA LA IMBRUVICA CAPS 70MG 5 PA LA IMBRUVICA CAPS 140MG 5 PA LA MO INLYTA TABS 5MG 5 QL (120 EA per 30 days) PA LA INLYTA TABS 1MG 5 QL (180 EA per 30 days) PA LA IRESSA 5 PA LA MO JAKAFI 5 QL (60 EA per 30 days) PA LA LENVIMA 10 MG DAILY DOSE 5 PA LA MO LENVIMA 12MG DAILY DOSE 5 PA LENVIMA 14 MG DAILY DOSE 5 PA LA MO 33

34 LENVIMA 18 MG DAILY DOSE 5 PA LA MO LENVIMA 20 MG DAILY DOSE 5 PA LA MO LENVIMA 24 MG DAILY DOSE 5 PA LA MO LENVIMA 4 MG DAILY DOSE 5 PA LENVIMA 8 MG DAILY DOSE 5 PA LA MO LYNPARZA CAPS 50MG 5 PA LA MO MEKINIST 5 PA LA NEXAVAR 5 PA LA ODOMZO 5 PA LA SPRYCEL 5 PA STIVARGA 5 PA LA SUTENT 5 PA TAFINLAR 5 PA LA TAGRISSO 5 PA LA TARCEVA TABS 100MG, 150MG 5 QL (30 EA per 30 days) PA LA TARCEVA TABS 25MG 5 QL (90 EA per 30 days) PA LA TASIGNA 5 PA TYKERB 5 PA LA VENCLEXTA STARTING PACK 5 PA LA MO VENCLEXTA TABS 10MG, 50MG 4 PA LA MO VENCLEXTA TABS 100MG 5 PA LA MO VOTRIENT 5 PA LA XALKORI 5 PA LA ZELBORAF 5 PA LA ZYDELIG 5 PA LA MO ZYKADIA 5 PA LA Monoclonal Antibody/Antibody-Drug Conjugate HERCEPTIN INJ 150MG 5 PA KEYTRUDA 5 PA MYLOTARG 5 PA LA RITUXAN HYCELA 5 PA LA RITUXAN INJ 5 PA LA TECENTRIQ 5 PA LA Retinoids bexarotene 5 PA PANRETIN GEL 5 QL (60 GM per 30 days) MO TARGRETIN GEL 5 QL (60 GM per 30 days) PA tretinoin caps 10mg 5 MO 34

35 Treatment Adjuncts ANTIPARASITICS ELITEK 5 mesna 4 MESNEX TABS 5 MO Anthelmintics ALBENZA 5 MO BILTRICIDE 3 MO EMVERM 5 MO ivermectin tabs 3 MO Antiprotozoals ALINIA 5 MO atovaquone 4 PA MO atovaquone/proguanil hcl 4 MO chloroquine phosphate tabs 2 MO COARTEM 4 MO hydroxychloroquine sulfate tabs 3 MO mefloquine hcl 3 MO NEBUPENT 4 B/D MO PENTAM MO primaquine phosphate tabs 3 MO quinine sulfate caps 324mg 4 PA MO Pediculicides/Scabicides lindane sham 3 MO malathion lotion 4 MO permethrin crea 4 MO ANTIPARKINSON AGENTS Anticholinergics benztropine mesylate inj, tabs 2 PA MO trihexyphenidyl hcl 2 PA MO Antiparkinson Agents, Other amantadine hcl tabs 3 MO amantadine hcl caps, syrp 4 MO entacapone 4 MO Dopamine Agonists APOKYN INJ 30MG/3ML 5 QL (60 ML per 30 days) PA LA bromocriptine mesylate caps, tabs 4 MO NEUPRO 4 MO pramipexole dihydrochloride 2 MO 35

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